Advances in the Treatment of Intermediate and Posterior Uveitis

Samantha Fraser-Bell; Carlos Pavesio

Disclosures

Expert Rev Ophthalmol. 2008;3(4):449-456. 

In This Article

Abstract and Introduction

Owing to the propensity for visual loss, immunosuppressive treatment in the form of systemic and/or local therapy is often required for the management of noninfective intermediate and posterior uveitis. Systemic corticosteroids are often used initially as they are fast acting, potent and inexpensive. However, other agents may be introduced, either owing to a lack of response to the steroids or to reduce the amount of corticosteroid required. This review explores new therapeutic options and will therefore concentrate on newer steroid-sparing immunosuppressives - the antimetabolite mycophenolate mofetil and biological agents, such as infliximab and interferon) - and on local therapy, such as intravitreal injections and implants). Well-conducted, randomized clinical trials are still required to confirm their benefit.

Uveitis is a group of inflammatory disorders that primarily involves the uvea but may also involve adjacent tissues. Intermediate uveitis occurs when the primary focus of inflammation is the vitreous, whereas in posterior uveitis it is the retina or choroids.[1,2] There are infective and noninfective causes. Intermediate and posterior uveitis may occur as a primary ocular process or as a manifestation of systemic disease. They account for much of the visual loss associated with uveitis due to their high rates of complications, including cystoid macular edema (CME), subretinal and epiretinal fibrosis, retinal detachment, optic nerve atrophy, glaucoma, and cataract. A European study involving over 500 patients with posterior uveitis reported that up to 35% suffered from blindness or visual impairment.[3] Furthermore, 10-15% of blindness in the USA is attributed to uveitis.[4] Owing to this propensity for visual loss, immunosuppressive treatment in the form of systemic and/or local therapy is often required. There have been changes in the management of uveitis over the last few years, with immunomodulatory agents and new intraocular delivery systems. This paper provides a summary of new treatment modalities for noninfective causes of intermediate and posterior uveitis.

The choice of treatment for noninfectious inflammatory uveitis depends on the diagnosis, the severity of the disease, the presence of concurrent systemic disease requiring immunosuppression, the duration of inflammation, the reversibility of visual loss and whether it is unilateral or bilateral. Other factors that need to be considered when choosing treatments are due to drug-related side effects and interactions, including the general health of the patient (e.g., the presence of other diseases including diabetes, renal failure, liver dysfunction and hypertension), and patient compliance to medication and follow-up. Systemic corticosteroids are often used initially as they are fast-acting, potent and inexpensive. However, other agents may be introduced, either due to a lack of response to the steroids or to reduce the amount of corticosteroid required (and hence to limit their side effects). These other agents include local options such as corticosteroid implants and injections, steroid-sparing immunosuppressives and biological agents. This paper explores new therapeutic options and will therefore concentrate on newer steroid-sparing immunosuppressives, (the antimetabolite mycophenolate mofetil [MMF] and biological agents, such as infliximab and interferon) and on local therapy (e.g., intravitreal injections and implants).

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